PHA 2011 Dues Invoice

Please provide us with your:   

PHA Physician Member: ____________________

  Group or Practice Name: ________________

  National Provider Identifier Number (NPI):

 

2011 Dues  ...........................................$325.00

     

We can now accept payments with MasterCard or Visa.

Please fill out the information below:

 

Card Holder:  _______________________________________

Card Type:  __________________________________________

Credit Card Number:  __________________________________

Expiration Date:  _____________________________________

 

OR, make check payable to:  “Physician Hospital Alliance”

 Please return payment to the address below:

Physician Hospital Alliance

2115 Leiter Road, Suite 400

Miamisburg, OH  45342-3659

 

If you have any questions please call Carol Baugh at (937) 384-6951.  

Please Note:  If the enclosed payment reflects membership dues for more

than one physician in your group, please list each physician’s name.